Reptile Initial Consult History Form

Reptile Initial Consult History Form
Your Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
We ask for your date of birth to ensure we meet regulatory guidelines when providing medications for your pet. Thank you for your understanding and cooperation!
Your date of birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you already scheduled an initial consult with PETS Referral Center for this pet?*

YesNo
Primary Care Veterinarian:
Enter N/A if you do not have one
Reason for scheduling appointment: *
Pets name*
Sex*
How was your reptile sexed?*
Approximate age *
What species is your pet?*
(i.e. Bearded dragon, leopard gecko, etc)
Does your pet have a microchip?*
Where did you acquire your pet?*
Date acquired?*
When did your reptile last shed?
Did the shed appear normal?
Do you have other pets?*
If yes, please specify:
Is your pet kept*

IndoorOutdoorBoth
Please describe (in detail) your reptiles enclosure: *
What do you use on the bottom of the cage? *
What type of heat source (if any) do you use? *
What is the high-end temperature of the enclosure? *
Low end temperature? *
How is the temperature measured? *
What is the humidity and how is it measured?
What light source(s) are used? *
Please include the brand name if known
When was the light source last replaced? *
Do you have a UVB bulb? *
If yes, list what brand and how often it is changed:
How often is the cage cleaned and what products are used?*
Do you soak your reptile? *
If yes, with what frequency and where?
Has your pets environment changed recently? *
(Cage, toys, etc.)
If yes, please describe:
What kind of foods are offered to your reptile and in what overall percentage? *
(i.e. 50% greens, 50% insects)
If insects are fed to your reptile, what do you feed the insects?
What is the source of any live insects you offer?
Do you give your reptile any supplements? *
If yes, what type and how often?
Please include brand name if known
Any recent diet changes or new food? *
If yes, please describe
Are you here for a wellness visit?*
If no, what problem(s) are you concerned about?
How long have you noticed the problem(s)?
Has your pet received treatment for this problem?
Has your pet been sick previously? *
Has your pet ever been seen by any other Veterinarians? *
If yes, when and why:
Name of Veterinarian(s)
Is your pet currently on any medication(s)? *
If yes, which medication(s) and what amount?
Note any other concerns or questions you have today that have not been addressed above:
Should be Empty:

Reptile Initial Consult History Form

We ask for your date of birth to ensure we meet regulatory guidelines when providing medications for your pet. Thank you for your understanding and cooperation!